Hemorrhoids, also called piles, are swollen, enlarged veins in the anus and lower rectum, similar to varicose veins. Everyone is born with hemorrhoidal tissue as a normal part of their anatomy, made up of blood vessels, connective tissue and a small amount of muscle. It only becomes a problem, known as hemorrhoidal disease, when this tissue swells and produces symptoms.
There are two main types depending on location. Internal hemorrhoids form inside the rectum, beneath a lining that is not sensitive to pain. External hemorrhoids form under the skin around the anus, which is sensitive.
Hemorrhoids are very common. An estimated 1 in 20 people have hemorrhoids that cause bother, and they become more common with age, affecting more than half of people over the age of 50.
Symptoms differ according to the type of hemorrhoid.
Internal hemorrhoids are usually painless and often cannot be seen or felt. They may cause:
- Painless bleeding, seen as bright red blood on toilet paper, on the stool or in the toilet bowl
- Prolapse, where a hemorrhoid pushes through the anal opening, which can cause pain, itching, irritation, mucus discharge and difficulty cleaning after a bowel movement
External hemorrhoids may cause:
- Itching or irritation around the anus
- Pain or discomfort, especially when sitting
- Swelling, or one or more hard, tender lumps near the anus
- Occasional bleeding
A thrombosed external hemorrhoid occurs when blood pools and clots inside the hemorrhoid. This causes sudden, severe pain, swelling and a hard, discoloured lump near the anus. The pain typically worsens over the first two to three days and then eases over the following days.
Causes and Risk Factors
The exact cause of hemorrhoids is not known, but they are linked to increased pressure in the lower rectum and anal area. Contributing and associated factors include:
- Straining during bowel movements
- Chronic constipation or diarrhea
- Sitting on the toilet for long periods
- A low-fibre diet
- Pregnancy, due to the pressure of the baby on the anal area
- Obesity or being overweight
- Aging, as the supporting tissues weaken
- Regularly lifting heavy objects
- Heredity
Diagnosis
Hemorrhoids are diagnosed through a review of symptoms and an examination:
- Visual inspection of the area around the anus, which can reveal external and prolapsed hemorrhoids
- Digital rectal examination, using a gloved, lubricated finger to feel for swollen veins, tenderness, lumps and muscle tone
- Anoscopy, using a short lighted tube to view the lining of the anus and lower rectum
- Colonoscopy or flexible sigmoidoscopy, used when needed to look higher in the colon and rule out other causes of bleeding such as polyps and colorectal cancer
Because bleeding can have other causes, evaluation is important, and everyone aged 45 and older should be up to date with colorectal cancer screening.
Treatment and Management
Conservative, at-home measures are the first-line treatment regardless of grade:
- A high-fibre diet or fibre supplements, aiming for roughly 25 to 35 grams of fibre per day
- Drinking plenty of fluids
- Stool softeners
- Sitz baths, sitting in warm water for 10 to 20 minutes several times a day
- Over-the-counter topical creams, ointments or suppositories for pain, swelling and itching, typically for about a week
- Over-the-counter oral pain relievers
- Avoiding straining and limiting time spent on the toilet
With conservative treatment, pain and swelling usually decrease within a few days, and most prolapsed internal hemorrhoids resolve without further treatment.
Office-Based Procedures
For internal hemorrhoids that do not respond to home care, several procedures can be done in the office:
- Rubber band ligation — a band is placed at the base of the hemorrhoid to cut off its blood supply, so it falls off within about a week; used for grades I to III
- Sclerotherapy — a solution is injected to shrink the hemorrhoid; used for grades I and II
- Infrared coagulation — infrared light creates scar tissue; used for grades I and II
- Electrocoagulation — an electric current creates scar tissue
Prevention
- Eat high-fibre foods and consider a fibre supplement, adding fibre gradually
- Drink plenty of fluids
- Avoid straining or holding your breath during bowel movements
- Do not sit on the toilet too long, and go when you feel the urge
- Stay physically active
Surgery
For larger or persistent hemorrhoids:
- Hemorrhoidectomy — surgical removal, the most complete method, used for large external hemorrhoids, combined internal and external disease, and grade III to IV prolapse; highly effective but with more discomfort and a longer recovery
- Stapled hemorrhoidopexy — repositions and removes internal tissue, generally less painful than a hemorrhoidectomy but not suitable for external hemorrhoids
Fewer than 1 in 10 people with symptomatic hemorrhoids need surgery. A painful thrombosed external hemorrhoid may be treated with an in-office procedure to remove the clot, usually within the first two to three days.
When to See a Doctor
See a doctor if there is bleeding during bowel movements, or if hemorrhoids do not improve after about a week of home care. It is important not to assume that rectal bleeding is due to hemorrhoids, especially if there is a change in bowel habits or a change in the colour or consistency of stool. Rectal bleeding can be a sign of other conditions, including colorectal cancer and inflammatory bowel disease, so all rectal bleeding should be evaluated. Hemorrhoids themselves do not cause or increase the risk of colorectal cancer, but other conditions can cause similar symptoms.
Seek urgent care for large amounts of rectal bleeding, lightheadedness or faintness, or severe anal pain and bleeding accompanied by abdominal pain, diarrhea or fever.